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APPENDIX B: TITLE VI COMPLAINT FORM <br />Section I: <br />Name: <br />Address: <br />Telephone (Home): <br />Telephone (Work): <br />Electronic Mail Address: <br />Accessible FormatLar <br />Requirements? <br />a Print <br />Audio Tape <br />TDD <br />Other <br />Section II: <br />Are you filing this complaint on your own behalf? <br />Yes* <br />No <br />*If you answered "yes" to this question, go to Section III. <br />If not, please supply the name and relationship of the person for <br />whom you are complaining: <br />Please explain why you have filed for a third party: <br />Please confirm that you have obtained the permission of the <br />aggrieved party if you are filing on behalf of a third party. <br />Yes <br />No <br />Section III: <br />I believe the discrimination I experienced was based on (check all that apply): <br />[ ] Race [ ] Color [ ] National Origin <br />Date of Alleged Discrimination (Month, Day, Year): <br />Explain as clearly as possible what happened and why you believe you were discriminated against. Describe all <br />persons who were involved. Include the name and contact information of the person(s) who discriminated against <br />you (if known) as well as names and contact information of any witnesses. If more space is needed, please use the <br />back of this form. <br />Section IV <br />Have you previously filed a Title VI complaint with this agency? <br />Yes <br />No <br />Title VI Program (2017 Update) <br />Page 19 <br />P128 <br />